Provider Networks Must Ensure Access to Pediatric Specialty Providers

Provider network requirements must ensure that health plan provider networks have the capacity to care for children with all levels of complexity, from basically healthy children in need of primary care to children with very serious, chronic or rare conditions. To serve children adequately, networks must include one or more appropriate pediatric hospital providers that maintain comprehensive pediatric specialty services, without administrative or cost barriers to care.

Unfortunately, a growing number of commercial health plans have limited provider networks that are incapable of delivering all of the pediatric services covered by the plan, from the most routine to pediatric specialty care. As a result, children may not have access to high quality, well-coordinated care when they need it. Lack of pediatric specialty care in networks, lack of transparency in coverage, burdensome pre-authorization processes, and high cost sharing place children and their families at financial risk and threaten children’s long-term quality of life.

When children are suffering from serious acute or chronic conditions, the variability of their conditions requires the refined clinical capabilities and capacity of the pediatric specialty care found only in children’s hospitals. The children’s hospital’s role is to provide the specialty services that a child needs so that families have the assurance of access to appropriate and timely care for their child.

Although children’s hospitals are less than 5 percent of all hospitals in the U.S., they account for 45 percent of all pediatric inpatient days. Children’s hospitals serve the majority of children with serious illnesses and complex chronic conditions and most children in need of major surgical services. Children’s hospitals provide almost all of the care for children with cancer, cardiac conditions, cystic fibrosis and spina bifida who require intensive specialty services.

While all children’s hospitals provide local care, they also excel in specialty care, meaning that children throughout large geographic regions have access to pediatric specialists, services and technology not found in community or adult hospitals. Preliminary analyses from the Children’s Hospital Association indicate that:

Children’s hospitals provide, on average, more than six times the number of selected pediatric services than seen in non-children’s hospitals, and have more than 25 times the number of pediatric designated beds (Analysis of the availability of pediatric specialty services in 13 states).

Children’s hospitals see greater than 60 percent of all occurrences for 21 different pediatric services (Based on a three-state survey of children’s hospitals). For example, in three states surveyed, children’s hospitals provide care to more than 80 percent of the pediatric population in need of rheumatology services.

Delays in accessing timely and appropriate care can be expensive and lead to poor quality outcomes for children with serious illness. Children who receive care from less qualified, experienced, or able providers may experience adverse outcomes, which not only threaten their very health and well-being in the short and long-term, but result in higher costs for the family, provider and payor.